The "Childmyths" blog is a spin-off of Jean Mercer's book "Thinking Critically About Child Development: Examining Myths & Misunderstandings"(Sage, 2015; third edition). The blog focuses on parsing mistaken beliefs that can influence people's decisions about childrearing-- for example, beliefs about day care, about punishment, about child psychotherapies, and about adoption.
See also http://thestudyofnonsense.blogspot.com

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Friday, February 26, 2016

Why Some People Who Should Know Better Still Assume That Reactive Attachment Disorder Involves Violent Behavior

Both professional journals and little independent
blogs like this one have been stating for years that Reactive Attachment
Disorder may be accompanied by aggressive behavior, but it is not the cause of
that behavior, nor is aggressive behavior a symptom of the disorder. The last
word about this was thought to have been said by the joint task force on
Reactive Attachment Disorder of the American Psychological Association,
Division 37, and the American Professional Society on Abuse of Children, headed
by the late, much-respected, Mark Chaffin (Chaffin et al, 2006).

Nevertheless, both parents and mental health
professionals continue to assume that “the list” promulgated by attachment
therapists, including not only aggression, but “fascination with blood and
gore”, cruelty, and unwillingness to make eye contact on the parents’ terms, is
an accurate description of Reactive Attachment Disorder. This is even evident
in master’s and doctoral theses, which are presumably approved by a committee
whose members are regarded (by someone) as knowledgeable.

Why? Why doesn’t this trailing edge pass over us?
There are lots of reasons why people believe foolish things, and no doubt they
all apply, but there is more to it than that. The problem I want to point to
today has to do with the failure of editors and reviewers to properly monitor
publications in professional journals, and the resulting publication of
inaccurate and misleading claims.

Let’s look at three such publications that I
stumbled across while looking for something else.

Taft, R.J.,
Ramsay, C.M., & Schlein, C. (2015). Home and school experiences of
caring for children with Reactive Attachment Disorder. Journal of Ethnographic &
Qualitative Research, 9, 237-246. [these authors appear to work in
special education and curriculum]

Taft et al state that “Children with RAD demonstrate
significant and often dangerous behaviors..” (p.238). They follow this
statement with a reference to the DSM-IV diagnosis, but without noting that
none of the DSM editions refers to dangerous behavior. In a later paragraph,
they reference an attachment therapy practitioner as saying (incorrectly) that
children with RAD defy traditional treatment , and then go on to say that the
Chaffin et al (2006) APSAC-DIV 37 task force reported that “some RAD children
exhibit extreme disturbances”—whereas in fact Chaffin et al acknowledged that
extremely disturbed childhood behavior is possible, but did not connect it with
RAD. Later, Taft et al describe the children as “very intentional” about
threatening or inappropriate behaviors, and state that concerning behaviors are
purposeful and directed toward targets rather than the results of temper
tantrums or responses to specific triggering circumstances. These statements
were based on interviews with parents, most of whom attended a RAD support
group (where presumably they told each other these stories and perhaps competed
to be the bravest or most martyred parent). The paper’s reference section
includes Nancy Thomas, a major promulgator of inaccuracies about Reactive
Attachment Disorder, and Michael Trout, a member of APPPAH and believer in
prenatal attachment.

Shi, L.
(2015). Treatment of Reactive Attachment Disorder in young children: Importance
of understanding emotional dynamics. American
Journal of Family Therapy, 42, 1-13. [this author is a marriage and
family therapist]

Shi describes the case
of a four-year-old boy, prenatally drug-exposed, and fostered by a sequence of
five families, one of which was said to have chained him to a table. The
current foster parents at the time of writing had three bio children and two
other foster children in the house as well as this child; the foster mother ran
a day care in her house while attending community college part-time. The father
wanted to give the child up, but the mother resisted this. In spite of some
obvious environmental problems past and present, Shi diagnosed the child as
having Reactive Attachment Disorder. Shi stated that the child fit the
“classic” RAD picture as described in DSM-IV-Tr, and then immediately proceeded
to describe the child’s relevant behaviors, none of which are described in the
DSM discussion.

The behaviors in
question were, first, “a persistent fear
state. He would eat non-stop when food was on the table and would not stop
eating until he was forced to. He would steal food and hide it in his bedroom.
He would eat garbage… shampoo and charcoal.” [N.B. these statement were exactly
as I have given them here, with no evidence of a persistent fear state actually
being given—JM].

A second category of
behaviors was “dysregulation of affect. He
urinated on the carpet when he was upset. …He broke toys on purpose, left holes
in walls…ruined furniture, abused family pets, bounced on his two-year-old
sister… He would not show emotions when hurt or injured but would cry
dramatically over small, insignificant things.” The connection between
urinating on the carpet and dysregulation of affect was not made, but as was
the case for the fear state, neither the categories nor the specific behaviors
are discussed in DSM.

A third category was “avoidance of intimacy…any attempt at
physical contact would result in his screaming at the top of his lungs. He had
no tolerance for anything soft or comforting. He… slept on a bare mattress. He
would fake emotions from time to time yet any genuine feelings and emotions
were scarcely observed.” Shi did not comment on how it could be detected that
the child was faking an emotion, or how reluctance to lie on bedding was
equated with avoidance of intimacy.

Treatment involved play
therapy sessions, plus the prescription of ten minutes one-on-one with the
foster mother every day. (The foster father also left the home, a factor that
was not further discussed.) In an outcome described as “magical” and a
“miracle”, after 16 sessions the child got a lot better and maintained his
gains over several years, during which the foster mother worked to adopt him. Certainly
the therapist and foster mother deserve full credit for their commitment and
their work with this child, but the assumption that they were “treating RAD”
was never justified.

From the abstract onward, this paper shows serious
confusion about the nature of Reactive Attachment Disorder and about the development of attachment. The
title refers to RAD, but the abstract speaks of disordered or disorganized
attachment. In reality, disorganized attachment behavior is a category used
when assessing toddler attachment by means of the Strange Situation. Young
children with disorganized attachment behave in unusual ways when reunited with
the mother after a brief separation, freezing in place, falling to the ground,
or backing toward the mother. The mothers may look frightened of the children
and are often suffering from traumatic experiences. This kind of behavior is by
no means a positive sign or a predictor of excellent development, but neither
is it a symptom of a clear-cut pathology or of Reactive Attachment Disorder.
Disorganized attachment reveals a situation in which both mother and child are
in need of help to recover from trauma, but it need not be associated with
separations or with abusive or neglectful treatment of the child; Reactive
Attachment Disorder is by definition found after situations of neglect
(sometimes including abuse) or multiple separations associated with neglect.

Having gotten off to a bad start on this paper,
Stinehart et al then compound the problem by stating their inaccurate position
on the development of attachment. Here’s what they say: “even before birth, a
fetus begins to form an attachment to the woman carrying it. After birth, an
infant will display an almost biological need [?—JM] to attach to a primary
caregiver, typically a mother… [this relationship] is consistently strengthened
as a child is comforted when scared, fed when hungry, and in general is made to
feel safe and secure. An infant will seem to seek an unbroken gaze into the
caregiver’s eyes and may attempt to mirror the caregiver’s facial expressions…”.
The authors next repeat their problem from the abstract, by referring in one
paragraph to disorganized attachment and proceeding in the next to discuss RAD,
implying without either argument or evidence that the first is to be identified
with the second. Finally (for the present purposes), Stinehart et al list a
series of symptoms that they declare to be part of Reactive Attachment
Disorder: early feeding problems, colic, failure to thrive, food hoarding,
gorging, and pica, lack of impulse control and of empathy, tantrums,
depression, inattentiveness, antisocial actions, cruelty, etc., all as seen in
various on-line lists but not in DSM.

To comment briefly on these claims: 1. Attachment does
not begin before birth; 2. Attachment is thought to develop as a result of the enjoyable
social interactions that usually accompany the caregiving routines mentioned by
Stinehart et al. 3. Infants do not make a great deal of eye contact until at
least 4 or 5 months of age. 4. When they do make eye contact, the unbroken gaze
is only a few seconds in length, as the child looks away to other parts of the
face or to other objects, then returns to mutual gaze briefly. 5. Mirroring
caregiver facial expressions occurs within a day after birth in the right
conditions, and is probably far more important in attracting the caregiver to
the baby than in establishing the baby’s attachment. 6. Need I say again that
although disorganized attachment indicates a relationship that needs support,
it is not the same thing as Reactive Attachment Disorder? No one has
demonstrated a connection between these two behavior patterns. 7. Once again,
although children may display all the problems on the list, and need help if
they do, these problems are not symptoms of Reactive Attachment Disorder.

How did these three papers get published? One reason
is that professionals trained in fields that do not involve child mental health
have convinced themselves that it is easy to pick up a developmental psychology
background that has been missing from their studies. But, more directly and
importantly, journal editors in those
fields, who cannot be expected to know all
the material relevant to every submitted paper, err by choosing reviewers who
are also untrained in child development. Thus, there is approval of publication
of claims that contradict established information and favor pseudoscientific
views of children’s mental health. Once publication has taken place, there is
no recalling the material, even when an editor revokes a published paper; it
stays somewhere on the Internet as a “peer-reviewed” publication.
(Unfortunately, this is all too often right, as the reviewer is apparently an
equal of the author with respect to understanding the issues.)

Editors and reviewers for guilty journals need to do a better job. Allowing misinformation
to be published is harmful to children and families in ways that are difficult
to undo once they have occurred.

I doubt it, because really it's only psychiatrists and psychologists who are on those DSM committees, and the ones who are on there are pretty stringent-- see the failure to get "developmental trauma" in.

Dear Jean MercerRobert Hafetz sent me a link to a listing of its methods. I want to ask you ...... whether it makes sense to do a professional translation of this technique and use in Russian conditions? Please give professional advice.https://independent.academia.edu/RobertHafetz

Dear Mikhail-- I would much rather see you translate different work, for example that by Mary Dozier about educating adoptive parents to do what their children need. I do not say that Haftez's techniques are harmful, at all. However, he seems to have made the mistake of thinking that all adopted children have the same problem no matter at what age they were adopted. He stated in a discussion with Pennsylvania legislators that a person who had been adopted three days after birth was depressed as an adult because of his separation from the birth mother. This is nonsense, and it opens the door to further nonsense if it is accepted-- it can even lead adoptive parents to accept cruel treatments (although once again, I see nothing inappropriate in the parental behavior Hafetz suggests).

About Me https://en.wikipedia.org/wiki/Jean_Mercer

Jean Mercer has a Ph.D in Psychology from Brandeis University, earned when that institution was 20 years old (you do the math). She is Professor Emerita of Psychology at Richard Stockton College, where for many years she taught developmental psychology, research methods, perception, and history of psychology. Since about 2000 her focus has been on potentially dangerous child psychotherapies, and she has published several related books and a number of articles in professional journals.
Her CV can be seen at http://childmyths.blogspot.com/2009/12/curriculum-vitae-jean.mercer-richard.html.